Wovon man nicht sprechen kann, darüber muß man schweigen.

I've never read anything by David Foster Wallace, but I know he's got
an intense readership. I also know he ultimately killed himself after
30+ years (started when he was 16) of depression. He had been on and
off meds, many didn't work, and Nardil had managed to stabilize him for
a while.

There were other important reasons to get off Nardil. The drug could
create problems with his blood pressure, an increasing worry as he
moved into middle age. In the spring of 2007, when he went to the
Persian restaurant and left with severe stomach pains, the doctor who
told him that Nardil might have interacted badly with his meal added
that there were better options now--Nardil was "a dirty drug."

This passage-- especially the last two words-- stayed with me for a while. I actually had a dream about it. "Dirty drug." I could hear the "psychopharmacologist" (that's apparently what the doc called himself) saying it.

To me those two words symbolize everything that is wrong with psychiatry today.

I.

To
a psychiatrist, "dirty" means the drug binds to what what makes it
efficacious (e.g. serotonin receptors) but also a lot of other places
that cause
different side effects. For example, Pamelor is a dirty drug because
it binds to histamine (sleepiness) and alpha1
(orthostasis/lightheadedness), M1 (dry mouth, constipation), etc.
Prozac is an SSRI-- a selective serotonin reuptake inhibitor-- it does
the one thing (serotonin) and nothing else.

No one says Prozac is more efficacious than a dirty drug, we say it has less side effects (sedation, constipation, etc.)

The problem is that there
is no reason
to make the distinction between effect and side
effect. I get that constipation and sleepiness are "bad," but how do
you know the receptors H1, M1, and alpha1 are also working in some
other way to generate efficacy? Or that you don't need all of the
receptors together with serotonin?

The
fact that we target serotonin for depression is a fact of
marketing, not of science; thirty years ago we could have gone with
dopamine reuptake inhibitors and bred a generation of Wellbutrin
clones. I'm not saying serotonin isn't relevant in some way; I'm
saying when Abilify treats depression, don't assume it was serotonin.
Or the dopamine. You simply don't know.

II.

My own observation: the words "dirty drug" are never preceded by the words "this is going to work awesomely because it's a."

As
far as biases go, one could speculate that the more receptors it binds
to, the better chance it has to work. Right? Why not? But we have
artificially chosen to believe the opposite.

The only time a psychiatrist would say "dirty drug" is when they're about to stop it.

Nardil caused a bad side effect for Wallace, and I can't fault the
doctors for attempting a change. But why say the words "dirty drug" to
the family?

He's
saying it because he's a cowboy, an idiot, he's using the psych lingo
to show he knows a lot about the drug-- "there are a hundred things
wrong with the drug, no time to explain now, trust me, I know what I'm
talking about."

The family is hanging on your every word, but
because of the high emotionality they don't detect nuance. They don't
know what you really mean, and they don't ask because they think it's
self-explanatory.

But psychiatrists love to use the lingo with patients, and no I have no idea why: dirty drug, augment, mood stabilizer.
Every time you use a psych term, even if it seems obvious, you are
telling them something different than you think you are telling them.

III.

The
article doesn't make clear who had heard the words "dirty drug"
spoken. Perhaps it is his wife, Karen Green; or it may have been his
sister, Amy, who in another article seems to have finished the thought:

"So at that point," says his sister Amy, with an edge in her
voice, it was determined, 'Oh, well, gosh, we've made so much
pharmaceutical progress in the last two decades that I'm sure we
can find something that can knock out that pesky depression without
all these side effects.' They had no idea that it was the only
thing that was keeping him alive." (emphasis mine, sarcasm hers.)

The
doc said, "dirty drug." Amy heard: "what kind of nut put David on such
a dangerous drug? Hello, it's 2008, we have way better drugs than
that! Thank God you came to us. Nardil? Are you f-ing kidding me?
What 1860s phrenologist came up with that? Did he try exorcism, too?"

Do you think Amy had any confidence to try and suggest that the Nardil be continued?

Note
the importance to Amy of this exchange. They were nervous about
changing, and I'm sure the doctor gave his reasons why he thought a
change would be beneficial. But he then said "dirty drug" which
conveyed incredulity and contempt. That's not me speculating, that's
Amy saying it. That, my friends, is real undue influence. This happens all the time.
If they had any reservations about changing the Nardil, that
obliterated them. As a family member, there is nothing you can say in
defense of a drug that a doctor has casually dismissed as dirty.

No
doubt, it reinforced her guilt that she hadn't been doing the right
thing for him; it reminded her of her stupidity, how could she not know
Nardil was dirty?

I'm not saying I wouldn't have changed the
Nardil (or that I would have). But the family never had the chance to
decide if Nardil was worth the risk, or not, because the doctor made it
very obvious that it wasn't.

Reminds of a few years ago, in the hospital, again, and on something like amitriptyline, clonazepam, Seroquel, lithium and lamotrigine from a previous, and recent, hospitalization. My pdoc decided to include Celexa in the mix. "That should hit all the receptors," she said. I kid you not. I just wanted to bang my head on the table but I couldn't because of the straight jacket.

You owe it to yourself, considering both your profession and your sense of humor, to at least read "The Depressed Person" and "Suicide As A Sort Of Present" from his collection "Brief Interviews With Hideous Men".

The real problem here is that the 'psychopharmacologist' is nothing of the sort. Adding an NRI would prevent hypertensive emergency, and MAOIs are good for people with essential hypertension. And, 'there are better drugs now' is bullshit, because MAOIs are the best antidepressants ever made. Sometimes i want to punch these idiots in the face; explaining to them things they already should know is far too good for them.

Just a thought: people actually dealing with their emotions, other people letting them, meditation, healthy lifestyles etc etc... Jesus, whatever, milking the cows. (Although we have no cows here.) One of my favourite New Yorker cartoons: Man in front of medicine cabinet trying to decide on the right pill -- labels have tragedy and comedy masks. Theatre and ritual... (Not Hollywood and Broadway.)

An interesting side effect of reading your blog (which I enjoy) is that I wonder very seriously about this field. I'm just not convinced. The rhetoric, the meds, the pomposity of thinking one can have the measure of another... with the other not even capable of taking his/her own measure... I'm babbling.

By the way, has anyone looked into Prozac's receptor binding profile? I don't quite understand what makes Prozac a "clean" drug when it binds to a zillion things other than the serotonin transporter. Oh, yes I do: "Clean" drugs are easier to market, right? That is until Effexor comes, and then you start making the argument that hitting more than one receptor system is actually better for you.

He's saying it because he's a cowboy, an idiot, he's using the psych lingo to show he knows a lot about the drug-- "there are a hundred things wrong with the drug, no time to explain now, trust me, I know what I'm talking about."

This happens in every field, apparently. Ask an average IT person if Windows Firewall is a useful security measure, and you'll get a similar dismissal ("Everyone knows it's garbage.") without elaboration (or with erroneous elaboration). MAOIs and Microsoft products are both maligned unfairly.

IT people are also similarly (inordinately, really) fond of using lingo to demonstrate the span and currency of their knowledge. Though there haven't been any fundamentally new technologies introduced in the last few decades, there are plenty of new terms that make it seem like there have been. Once everyone is familiar with the new terms, they lose their power of obfuscation and are discarded.

Weird how this readership seems to intersect so strongly with Wallace's. And when I say weird I mean "not weird at all, because some of the points you try to make are similar".

I don't know if you can really call this anything less than uninformed consent. Reading through Infinite Jest, you find a lot of references to pharmacology; maybe he wasn't an expert, but he was degrees of magnitude more informed than your typical rube. He wanted to get off Nardil, all he was looking for was permission. He even tried to get back on it, after the other drugs proved, uh, inefficacious, but apparently going off and then back on to an anti-depressant doesn't work every time. (Why is that?)

Weird how this readership seems to intersect so strongly with Wallace's. And when I say weird I mean "not weird at all, because some of the points you try to make are similar".

I don't know if you can really call this anything less than uninformed consent. Reading through Infinite Jest, you find a lot of references to pharmacology; maybe he wasn't an expert, but he was degrees of magnitude more informed than your typical rube. He wanted to get off Nardil, all he was looking for was permission. He even tried to get back on it, after the other drugs proved, uh, inefficacious, but apparently going off and then back on to an anti-depressant doesn't work every time. (Why is that?)

This is pure speculation: Preventing a depressive episode by acting on a "non-depressed" brain may involve some degree of distinct neurocircuitry/neurochemistry than what is modified by an antidepressant while the individual recovers from depression. Given how the environment, metabolism, and human brain change over time, it is plausible that a drug that was able to work for both tasks may lose its ability to accomplish one.

But psychiatrists love to use the lingo with patients, and no I have no idea why: dirty drug, augment, mood stabilizer.

What would you use in lieu of augment? "Helper drug?" I just never thought of "augment" as being psychiatric lingo. And what about mood stabilizer? Do you, instead, describe medications by their receptor activities?

Seriously, as a (soon to graduate) resident, I'd be interested to hear suggestions on how to communicate pharmacologic information to patients. I do realize that we've been our bubbles for so long that many of us forget how to talk in lay terms. I just always thought that I was good at communicating with patients, but I have to admit that I've used all three of those terms.

(I try to gauge my patients' educational level, and then adjust accordingly, but of course you're sometimes going to over- or underestimate a bit. Some are offended if you talk down to them, some come to their first appointment spewing more psycho-lingo than I even know, others wants me to break it down kindergarten-style. I'm happy to do any of the above, but people have to understand that despite best efforts, we're going to often miss the mark, especially during initial interactions with them.)

doesn't every profession love to use its lingo when dealing with clients?

You seem to advocate the evisceration of jaron generally. This is fair, jargon is foten confusing to the uninitiated but doesn't jargon also serve efficiency purposes.

Jargon is kind of like an established trademark: a way of communicating a lot of infromation in a concise way, between professionals, and a way of establishing authority, between professionals and their clients. It shows that you are familiar and comfortable with the conventions of the profession and many people may even feel MORE comfortable with a jargon-using professional than with one that uses lay terms.

In this case jargon is BAD because he was wrong. If DFW had instead gone on to recover and write a bunch of awesome books the same jargon-spewing professional may have been lauded. At least by david and his family.

Sure there is a kind of "bargaining power problem" between a psychiatirst and his patient as the patient has no real way to question his psych's decisions but patients can also go for a second opinion. And what's the point of going to a doctor if you aren't going to trust his authority? How many patients want to know the difference between drug x and drug y and how they work? Or can understand it.

Arguably, this is an especially important profession and thus should be subject to stricter regulations of jargon use. But how do we tell which professions can use jargon and which can't, when they can and can't, whith whom they can and can't. It's a line drawing problem and i think that the overall efficiency of jargon will probably outweigh the benefits of its destruction.

It's a line drawing problem and i think that the overall efficiency of jargon will probably outweigh the benefits of its destruction

I agree with your assessment of jargon as economical, but it does assume that it's also informative. Our host's love of Wittgenstein would indicate that he sees jargon, particularly more abstract jargon, as intellectual laziness. In Wittgenstein's world, language is only valuable for discrete "propositions," which relate a logical relation between "states of affairs." In this light, most language is subjective blather with no demonstrable truth.

Jargon is dangerous in that it serves as an artificial endpoint to understanding. The technical nature of jargon is mistaken as a sort of gravity and truth beyond more familiar vernacular. "Dirty drug" is a nonspecific descriptor that can be interpreted freely. The "drug" part is fine, but dirty is subjective. To the uninitiated, drugs are a mystery anyway, so to hear that one is "dirty" doesn't add anything to understanding, and doesn't invite inquiry for those cowed by the professional. They're free to imagine a myriad of things that make it dirty, and do. Dirty is their starting point and anchor.

"In Wittgenstein's world, language is only valuable for discrete "propositions," which relate a logical relation between "states of affairs." In this light, most language is subjective blather with no demonstrable truth."

I can see your point but that seems applicable mainly to this special case.

What we term things will always influence how others think about them. There is a huge difference in the onlookers perception between one who is "shell-shocked" and one who has "PTSD". We use the latter term and not the former for a reason.

The reason is an attempt to change how other percieve the sufferer and how he percieves himself. I don't know who this benefits, it may be just re-arranging chairs, but i would think this benefits the suferer at least to some degree.

At the very least people put a lot of "stock" in what we name stuff. I can say black person but i can't say nigger.

Finally, "dirty drug" may be a poorly thought out moniker when we look at how outsiders will percieve the advice the professional is giving but i think this may be just a function of the word "dirty" and is a simple enough problem to fix without eviscerating jargon.

I'm not against jargon; I'm against confusing people. When Jack Bauer on 24 says, "Engage! Engage!" that's jargon-- he means shoot them. But if there was a possibility that I would think he meant "marry them! marry them!" then he shouldn't use it _with me._

Sometimes jargon is meant to exclude the uninitiated-- fine. But to use it when it could easily be misinterpreted... when more accessible words would do.. see? Also, the pharmacologist used the jargon-- let's face it-- in order to impress. (Yes, it's speculation on my part.)

What's really sad is that mood stabilizer and dirty drug is psychiatric lingo, I'm sure these terms started out as terms used to dumb things down for patients, but they've come to be used as convenient cliches that only have meaning to psychiatrists.

As the March 9, 2009 New Yorker profile by D. T. Max makes clear, before David Foster Wallace's death there was a trail of the usual psychiatric misinformation and cluelessness, including that 3 minutes of consultation led to 22 years of Nardil prescription.

The conclusion that Wallace died because Nardil was keeping him alive is erroneous. Withdrawal of Nardil did not cause relapse of his depression -- it caused obvious antidepressant withdrawal syndrome.

Prolonged antidepressant withdrawal syndrome is almost always ignored, misdiagnosed, and mistreated by psychiatry.

Wallace suspected additional drugs were making him worse, and he probably was right. That's very common in withdrawal syndrome. Some patients become hypersensitive and prone to paradoxical reactions from any neurologically active medications or even vitamins.

Who wouldn't reasonably consider suicide if told he had a new, virulent, and apparently untreatable form of mental
illness?

I should know, I've had Paxil withdrawal syndrome for more than 4 years. 18 months ago, when I completely lost the ability to sleep because of it, I would have killed myself except that in the nick of time I found the one doctor in the world who can treat it, right here in San Francisco.

Disruption of sleep architecture is very common in antidepressant withdrawal syndrome, as is emotional blunting. (Heath Ledger died of self-medicating intractable insomnia after Zoloft withdrawal.)

The precipitating factor was not an inaccurate remark about a "dirty drug" (it's a fantasy that any of them are "clean"). Wallace was well-read about the drugs. He had suffered years of side effects. His life had progressed. His reasons for stopping Nardil made sense. But he was not prepared for withdrawal syndrome.

Wallace's death haunts me. If he had only known he had withdrawal syndrome, not an untreatable soul-killing relapse, and he would probably slowly recover from it....

Yes, academic psychiatry is dangerous. It has deliberately suppressed information about antidepressant withdrawal syndrome for more than a decade. Wallace's tragic, premature death nominally was by his own hand, but it was psychiatry that knotted the noose for him, as it has for thousands who suffer from antidepressant withdrawal syndrome.

While it may jump out at you as relevant, his story "The Depressed Person" is a bad place to start, IMO, just too irritating. Try "A Supposedly Fun Thing I'll Never Do Again", the volume of essays. Among other pieces, you get the title essay (his most popular article among most people, who love him for "that cruise ship travelogue" - and it is indeed awesomely witty in his own way). That volume also contains my personal favorite nonfiction piece of his, an extended essay on David Lynch.
(I think he nails a lot of thoughts on Lynch's oeuvre - he wrote it while visiting the set of Lost Highway - along with a lot of other things about movies and the film industry etc. etc.)

On another note, it's a tragedy how few clinicians understand or are willing to utilize MAOIs in practice nowadays. Their use is dying out, replaced by stereotypes and reflexive horror, and yet that class of drugs seems to be salvation for some, certainly not the "would you rather try ECT first?" sort of last resort.

The mere mention of MAOIs often makes a doctor's face contort, dizzy with liability in their eyes, as if a few strict dietary rules and perhaps a home blood-pressure cuff were somehow disaster compared to the AAPs that patients with treatment-refractory (unipolar) depression now get handed as "augmentation". Is hypertension really less of a problem when it comes on slowly, pressurizing like a balloon of Zyprexa-fueled visceral fat?

daniel wrote - "There is a huge difference in the onlookers perception between one who is "shell-shocked" and one who has "PTSD". We use the latter term and not the former for a reason."

Actually, doctors used to use "shell shocked" when they first started talking about what we now call PTSD after the 1st or 2nd world war. As our understanding of trauma and trauma's aftereffects became better, it was given a new name that reflected our better understanding, including realizing that PTSD isn't just associated with war.

daniel wrote - "The reason is an attempt to change how other percieve the sufferer and how he percieves himself. I don't know who this benefits, it may be just re-arranging chairs, but i would think this benefits the suferer at least to some degree."

Actually, it's a reflection of how medicine sees a certain condition at a certain time and not designed to manipulate the patient. That said, when dealing with the mind and brain (mind/body) in the context of PTSD - and many other contexts - you can create change through either the mind OR body. This is why something like meditation (or yoga), that harnesses mind and body, can be so useful for some people. So, how someone with PTSD thinks about the traumatic event and their current state is VERY important. PTSD is very much about how one's internal furniture is arranged (one's personal narrative) so dismissing how one frames and thinks of something as trivial is, well, silly since it's such a huge part of the condition. It's why CBT can be so effective with PTSD.

Daniel - "At the very least people put a lot of "stock" in what we name stuff. I can say black person but i can't say nigger."

You can say "nigger", it's just not equivalent in meaning to "black person" (when used by you or anyone else). Particularly when you consider the person in question to be "stuff" that "we name" - that tends to acerbate the association that the word "nigger" has to slavery and colonial oppression, and particularly to hate and violence, and the KKK, when used by a white American who sees people as "stuff we name". Do you feel the same way about the words "bitch" and "female"? Who are YOU trying to fool when you say "black person" when you're really thinking "nigger?

Words have meaning, how we use them adds other layers of meaning, as does the context they're used in. Alone is talking about the miscommunication that happens in medicine when hermetic/specialized language is used by a doctor but heard and interpreted by the patient using it's common meaning. Considering that psychiatry is historically very much about words and meaning, the symbolism of words and deeper meaning, it's rather pathetic if a psychiatrist isn't aware of word use. I'd assume that's one reason why the person in question was calling himself a "psychoparmacologist" and not a psychiatrist (my guess is that arrogance and narcissism plays into that choice too since it doesn't sound like he actually showed much pharmacological expertize ultimately).

I need to comment on one aspect of this post only. It dawns on me that many may understand the word "n*****" to construe only the meaning as commented here. And this bothers me deeply.

Though I ought to point out my post may also form a support of and perhaps a counterpoint to Alone's original thread and a recurring theme of his.

Anyone who has ever heard the word "n*****" used in its fully realized intent and purpose would *never* leave it presented as lightly as portrayed here. The actual use of the word conveys a meaning that (literally) draws from the darkest recesses of the human soul and psyche. That another human being is so beneath humanity and so vile that they are literally sub-human, and pose a contamination to humanity itself only begins to treat the meaning of this word in actual use. If you saw and therefore understand the amount and depth of hatred this word was actually used to convey you would want it to disappear in use except perhaps as a cautionary "turn back now" signpost at the edge of the very worst of man.

To my mind, and I cannot imagine one who actually understands this word to disagree, it is the most detestable word, in any language.

To my second point, in support of many of Alone's posts, words have meaning but also intent. More correctly perhaps (though how can you separate language and psyche), people's use of words, their communications have intent. And it is the careful, not superficial, hearing or reading of those words that responsible human beings should practice in order to derive not only the sentence but the intent.

Though, the counter-point can be seen in that words clearly have varying meaning, oftentimes even within groups closely tied in every way. Communication is a dicey prospect in the best circumstances, face to face and closely defined. When practiced in 'font' it is even more dangerous. I happen to agree with Alone though perhaps I differ in one respect. I agree that everything intended for a large audience has an agenda. And that practitioners are either more or less sophisticated in their ability to support their agenda. What we may disagree on is that I believe there is an inherent social structure embodied in myriad mechanisms that locks any and every practitioner into the same problem.

Anonymous - We're now moving beyond discussing dr/patient communication - not that contextually defined meaning doesn't come into play in that arena too.

As I pointed out, the word "nigger" comes laden with the baggage of slavery and isn't equivalent to "Black man". (As you illustrate, for many people it's an emotionally charged word with only negative connotations, and rightfully so.) As for it being the most hateful word in English, it's no more or less hateful than other words that are used with hateful intent to belittle, dehumanize, intimidate, exclude and oppress such as "faggot" or "dyke" or "whore" or "kike" or the myriad of other xenophobic slurs. While the word itself carries meaning, the intent and context also create meaning.

There was a trend towards reclaiming certain derogatory words that started in the 80s, words such as "Queer". The same happened in gangster and hip hop culture, and "nigger" used in this context can be used as a term of affection and inclusion (as well as a rejection of middle class assimilation and claiming of at least the power to incite fear). There has been and still is a lot of debate over this both within the communities reclaiming the words. However, even if some people in the hip hop community affectionately call each other "nigger" or people in the Gay community call each other "dyke" or "fag" when someone outside the community uses the term in a hate filled way it remains a derogatory slur. It's really not that complicated if you understand that language is fluid and context specific. Communication's not just about what's said but what's heard...when words can have multiple and context specific meanings, it's important to make sure both parties are working with the same lexicons. When we come from different social contexts with context specific lexicons - be it dr/patient or ghetto/suburbs - miscommunication often happens if both parties forget that language is context sensitive.

Great Post. This is too bad about Wallace. You should check out Charlie Rose interview with both Wallace and Jonathan Franzen. This was before Franzen hit major success with The Corrections. Interesting to see both in conversation, though there was a third writer featured who was clearly a throw-in and detracts from interview. Its on Google.

To only medicate--is to almost always refute the large body of scientific research. Dendritic growth and associative connectivity are certainly key to change, yet we focus on NT's as if they are the whole issue. Priming the synapse with Serotonin/Dopamine may sometimes help set the stage for neuroplasticity, but without an associated change in thoughts/actions/environment--its likely that our very plastic brains, find a way to depress more given no real change in life experience that is drives neurodevelopment.

This is why I believe Psychiatry has lost its way overall as a profession, sure focus on medication as the medicating professionals, but don't allow yourself to become awed by the over-simplistic NT research. When I took Neuroscience classes in the 90's we didn't know there were over a 100 NT's, and much of the research since then continues to be shown to be highly overstated and geared toward biological reductionism/nurture. There is no way for human beings to not exist both as an experssion of their genetics and learned behaviors/environmental stimuli/social-psychological experiences.

I've seen this many times as an M.D. tells the treatment team that the child is Bi-Polar (after spending 15mins with them) when if you look at the DSM their symptoms most closely relate to Borderline/or R.A.D. Let's be clear, they ideas that medicalizing somehow removes stigma is wrong minded--if it dehumanizes people's experience. So does telling all the children I work with who were raped, sadly, often by family members--"Gee Susy, you just have a biological disorder--take this pill you have bi-polar, we will just titrate you to make you sleep enough that hopefully your chronic anxiety-fear and self-defeating beliefs will just disappear". I hope that Medical doctors actually begin acting more like PCF with patients and not just viewing them as biological flawed, when there is much more to human beings.

Remember Patients come from the latin, "one who endures/or suffers" and let me be clear--most clients that carry these labels don't feel distigmitized and there are side effects of this mindset as well. I'll never forget one of the first children I met with, I was sent to the school, he was in the counseling room playing with toys. He looked at me and stated boldly, I have ADHD, that means I don't have to pay attention to you, its biological." Then he went back to paying attention to his toys.

Thanks crumbskull. I quite enjoyed (or rather, appreciated) the pieces from "Interviews with Hideous Men" by David F Wallace that you recommended. Even the "Adult World" series, from the very same book, is awesome.

For those who would like to read it, it is available for free (check your local laws for downloading copyrighted works) at:

Hi --
I've been waiting for someone to notice that psychiatric treatment (drugs, EST) and drug withdrawal, not depression, killed David Foster Wallace. Important read on harmful effects of long-term pschiatric drug use: Anatomy of an Epidemic by Robert Whitaker (2010).

I have never heard a psychiatrist use the term "dirty drug." I think you're tilting at windmills by castigating the poor journalist. Journalists get a lot wrong. They are under unbelievable time pressures to crank out stories (freelancers especially) and are expected to convey accurate information about an encyclopedia's worth of topics.

There has never been a documented case of hypertensive reaction with tyramine in the literature. Much recent literature is showing the fears regarding Nardil to be ill founded and unscientific. He may have gone off for no reason at all. However, Serotonin crisis can occur when SSRIs are mixed with Nardil, and not then not treated correctly with an agonist.
DL